Provider Demographics
NPI:1508348772
Name:BOESCH- LEVERETT, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BOESCH- LEVERETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 RIVER OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-4859
Mailing Address - Country:US
Mailing Address - Phone:678-427-7570
Mailing Address - Fax:
Practice Address - Street 1:265 SHERATON BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1359
Practice Address - Country:US
Practice Address - Phone:678-427-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001105133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered